Abstract

Introduction: The CDC report on oral health found that preschool children have increasing incidence of dental caries especially poor children. Profound disparities exist in dental services obtained by children, especially the poor. Objectives: The purpose of this project is to improve the oral health of vulnerable children via an interprofessional model through the Supplemental Nutrition Program for Women, Infants, and Children (WIC). Methods: This project tested the feasibility of integrating primary preventive interventions of oral health assessments/teaching, fluoride varnishing and referral to a dental home into regular practice at an urban and rural WIC site using nurses, registered dieticians and students. Results: After three years, 4091 children were enrolled and received fluoride varnish. Children who were seen by the nurse/dietician at the urban or rural WIC sites were found to have more children seeking dental services through a dentist between the 2nd and 3rd WIC visits (p<0.001). Children at both sites increased their brushing or cleaning their child’s teeth between the first and second visits (p<0.05 for the rural site; p<0.001 for the urban site). Conclusion: Interprofessional cooperation along with a community based approach is needed to tackle this increasing problem of early childhood dental caries.

Keywords

Introduction

Our nation’s children are suffering! They are suffering from dental
decay. The Surgeon General declared dental caries the “Silent Epidemic”.
Profound disparities exist in dental services obtained by children,
especially the poor. Even when providing dental services, children
with Medicaid were statistically less likely to be treated by a dentist
than those with private insurance, comparatively at percentages of 55%
versus 68% [1]. Poor and/or minority families are affected most [2] with
preschool children having increasing rates of dental caries compared to
other age groups [3]. Approximately 23% of children aged 2–11 years
have one or more untreated tooth decays and 20% of adolescents aged
12–19 years have one or more permanent tooth decays3. The American
Dental Association and the American Academy of Pediatric Dentistry
among others suggest the ideal standard is to establish a dental home by
one year of age. Of particular concern is the low rate of early detection
and preventive care for 3 year old and younger children eligible for
Medicaid due to a shortage of dentists who accept Medicaid and who
are willing to treat children. The CDC report on oral health found that
preschool children have increasing incidence of dental caries with the
prevalence of dental caries even higher in lower-income families3. Poor
children have higher rates of dental disease compared to other children
and their lack of access to dental care and untreated dental conditions
can contribute to poor health, dysfunctional speech, compromised
growth, and poor educational performance [4,5].

Successful primary prevention helps avoid the suffering, cost
and burden associated with disease. It is considered one of the most
cost-effective practices of health care. Therefore, an interprofessional
primary prevention approach in a community setting, serving children
and their caregivers focusing on dental education, oral hygiene skills,
fluoride varnish application and referral to dental home is one means to
manage this epidemic in low income children.

Children who receive early preventive dental care have 40% lower
dental costs over their lifetime than those who do not receive this care
[6]. Numerous studies demonstrate the value of applying fluoride
varnish to children’s teeth as a means of decreasing the incidence of
dental caries [7]. Caries reduction rates vary; however, a meta-analysis
of Duraphat trials reveals 38% reduction in cavities; semi-annual
application in 3-yr-olds produced a 44% reduction in two years [8].
In addition, primary health care providers can now be reimbursed
through Medicaid for fluoride varnishes to preschoolers as a primary
prevention method.

In this initiative, WIC eligible children (ages under 5) were
recruited. WIC (Supplemental Nutrition Program for Women, Infants,
and Children) is a national program that safeguards the health women,
infants, & children who are at nutritional risk by providing nutritious
foods to supplement diets, counsel on healthy eating, and referrals to
health care. WIC clients are low income; eligibility requires a gross
income at or below 185% of the U.S. Poverty Income Guidelines. WIC
was chosen because poor and/or minority families are affected most
with dental caries, with preschool children having increasing rates
of dental caries compared to other age groups [9,10]. Children from impoverished families as well as uninsured families were significantly
associated with feelings of caregiver burden, leading to less preventive
dental use. According to a recent study run by the Department of
Oral Health Sciences at the University of Washington, over 60% of
participating dental providers had out-of-pocket health care expenses
relating to a child’s oral condition, resulting in barriers stemming from
financial burden [11]. Poor and minority children under 5 years of
age are significantly less likely to have preventive or restorative dental
visits, and to have more unmet treatment needs and more caries than
non-minority children or those from higher incomes. Minority and
low-income groups have barriers to dental services due to limited
resources, competing family needs, and challenges related to providers
and insurance [5,12].

Even when Medicaid provides dental services, only 33% of
eligible children receive preventive or restorative dental service due
to a shortage of dentists who accept Medicaid and who are willing to
treat children [13]. Dentists only receive 60% of dental services billed
to Medicaid and, depending on the procedures, may not receive any
compensation. Accordingly, Michigan dentists were recently surveyed
in accordance to AAPD (American Academy of Pediatric Dentistry)
recommendations. Of the 229 participants, 47% were not willing to
accept Medicaid patients [14]. Projected Medicaid and State Children’s
Health Insurance Program cuts are expected to cause one million
or more children to lose health coverage that paid for dental health.
Uninsured children are 6 times more likely to lack a source of dental
care than insured children and four times as likely to have unmet dental
needs [15] and approximately one fourth of children in the U.S. do
not have any form of private or public dental insurance [3]. In Ohio,
dental care remains the most common unmet need for almost 157,400
children, regardless of financial status [16]. Primary care providers
and other health professionals are needed to prevent caries in young
children. Fewer than 3% of Medicaid children see a dentist before the
age of three, but 78% of children fewer than 3 years of age see a primary
health care provider and attend WIC [17].

Primary Causes of Tooth Decay

The bacterium S. mutans is the main contributor to tooth decay.
Adults may have higher amount of S. mutans in their mouth and can
transmit it to their infant or child through the exchange of saliva.
Frequent sugary snacking and drinking interact with S. mutans,
producing acids that can cause mineral loss from teeth increases the
risk for tooth decay. Dental caries affect more children in the United
States than any other chronic infectious disease. Tooth decay and other
oral diseases that can affect children are preventable. Fluoride varnish
can reduce cavities in preschool children by 30-40%. A panel of experts
from the American Dental Association (ADA) Council on Scientific
Affairs recently assessed 71 trials from 82 articles to establish the
efficacy of topical fluoride caries-preventive agents. The ADA currently
recommends 2.26 percent fluoride varnish for prevention of dental
carries in children ages 6 and younger [7] (Figure 1).

Figure 1: Tooth decay of the front top teeth (Child who participated in the
fluoride varnishing offered at one of the WIC sites).

Tooth decay of the front top teeth is referred to as Early Childhood
Caries (ECC) formerly called Baby Bottle Tooth Decay. Causes of
ECC include poor oral hygiene, not enough fluoride, sleeping with a
bottle or sippy cup, frequent snacking and bottle/sippy cup, feedings
containing beverages high in sugar, milk, or formula during the day
or night, coating pacifiers with sweeteners like sugar or honey, and
having a mother/caregiver or sibling who has had active tooth decay in
the past 12 months. ECC and tooth decay in general is a multifactorial
disease and a child could have a few of these factors and not have decay
while other children may have only one factor and have decay. Also some foods cause tooth decay more than others called cariogenic foods
ECC develop in young children who use Sippy cups or baby bottles
constantly and have poor nutrition with a history of eating frequently
or eating the wrong foods [18] (Table 1).

The process of decay is mostly influenced by sugars that can be
fermented by the bacteria in the mouth, causing a lower pH or acidic
environment [19]. This environment works on deteriorating the enamel
of the tooth. This demineralization will incite a cavity. Caries in the
primary dentition leads to the same in permanent teeth [20].

Another source of caries, aside from poor nutrition choices, is
infection. Mothers who pick up their child’s pacifier and put the pacifier
in their mouth to clean it off may inadvertently pass on the bacteria,
mutans streptococci, which cause dental caries. Along with passing
the infection by saliva and mouth kissing the baby, the frequency of
eating significantly increases the presence of mutans streptococci [21].
The constant change of the acidity of the mouth’s saliva will cause wear
down of the protective enamel setting up the possibility of decay. A
human’s saliva has the ability to cause re-mineralization of the tooth’s
enamel. Eating foods that keep the acidity of saliva high continues to
cause demineralization and the potential for dental caries. The more
the teeth are bathed in anything other than water or healthy saliva, the
greater the chance of demineralization. Despite our understanding of
the risk factors associated with caries in early childhood, caries remains
one of the largest untreated conditions in preschool children [22].

Ways to prevent dental disease

Early Childhood Caries (ECC) is defined by the American
Academy of Pediatric Dentistry (AAPD) as the presence of one or more
decayed, missing (as a result of caries), or filled tooth surfaces in any
primary tooth in a child 71 months of age or younger [23]. The AAPD
and the American Academy of Pediatricians (AAP) recommend that
primary care providers include the following oral health prevention
strategies: (1) perform periodic risk assessments to determine the child’s relative risk of developing dental caries; (2) provide anticipatory
guidance to parents about oral hygiene, diet, and fluoride exposure; (3)
apply appropriate preventive therapies, such as fluoride varnish; and (4)
help parents establish a dental home for their children by 12 months of
age [24].

Purpose of Project

In Ohio, dental care remains the Number 1 unmet health care need
of children and low income adults [16]. The purpose of this project is
to improve the oral health of low income pregnant women, mothers,
and children. WIC (Supplemental Nutrition Program for Women,
Infants, and Children) is a national program implemented by the State.
WIC clients are low income; eligibility requires a gross income at or
below 185% of the U.S. Poverty Income Guidelines. Regular contact
is mandated every 3-6 months between WIC staff and their clients,
WIC education includes oral health modules and WIC’s mission of
nutritional improvement has links to oral health.

Training non-dental specific health care professionals

The School of Nursing and the Nutrition and Dietetics at a
Midwest university have collaborated on many projects. Each program
also has educational and service relationships with local WIC sites in
urban and rural locations. The objectives from Healthy People 2020 support the improvement of oral health in vulnerable populations
[25]. Responding to these concerns, the School of Nursing proposed
an interprofessional approach to oral health in vulnerable children and
their at-risk mothers. This project employed Nurse Practitioners (NPs),
Registered Dietitians (RDs), and Registered Nurses (RNs) at urban and
rural pilot WIC sites, using a standard Ohio Department of Health
(ODH) protocol to apply fluoride varnish to the teeth of children
enrolled in WIC from the development of first tooth buds through
4 years of age. Additionally, the registered dietician’s (RD) scope of
practice was systematically expanded by training in fluoride varnish
application, oral health assessment and oral health prevention. The
project used Smiles for Ohio, the current Ohio Department of Health
(ODH) fluoride varnish program, which has well defined guidelines
and training programs for non-dental health care personnel on placing
fluoride varnish. This program is adapted from the AAP’s oral health
programs. The specificity and proven safety of these guidelines make
them an ideal template for use in an initiative to increase access to oral
health care. A NP, with a specialty in pediatric oral health, conducted
the training in standardized oral health assessment and varnishing
for NPs, RDs and RNs. Drawing on the current program guidelines,
the placement of fluoride varnish on children occurred after an oral
health assessment by a NP. In this project the NP or RD performed
the oral health assessment after completing the Smiles for Ohio oral
health training. The NP and RD developed picture ratings from the
AAP and AAPD to maintain inter rater reliability of what the RD and
NP labeled a cavity. After the oral health assessment, the NP or RD
administered the fluoride varnish to the child. Ongoing semi-annual
assessments of the child continued as long as the child was still in the
WIC program (under 5 years). The participants were tracked by the
RD/NP for fluoride intervention, and parents of the participating child
were provided education and referrals to dental homes for themselves
and their children. The NP and RD kept the child’s record secure in
their office. In addition, parents responded to survey questions at every
visit which were entered in SPSS by the evaluators. IRB approval was
obtained and permission from WIC was also obtained.

Project Goals

The goals of this project were to: 1) Improve oral health disease in this population; 2) Increase interprofessional collaboration by using
NPs, RDs, and RNs to conduct oral health assessments and apply dental
fluoride varnishes to at-risk children under five years of age; 3) Increase
oral healthcare accessibility by linking services and care at WIC sites
emphasizing preventive care, screening and fluoride varnishing, and
establishment of a dental home; 4) Increase oral health workforce
diversity, capacity, and flexibility through oral assessment and dental
fluoride varnishing training programs for NPs, RDs, and RNs; 5)
Increase interprofessional collaboration by using NPs, RDs, and RNs
to conduct oral health assessments and apply dental fluoride varnishes
to at-risk children through 4 years of age with dentist consultations, as
needed; and 6) Overcome oral health barriers by using best practices
and educational materials from established effective nutritional and
oral health professionals and programs. Successful completion of
this project will result in a model that can be used by WIC and other
assistance programs in Ohio and, perhaps, nationwide to enhance
oral health education to pregnant women and mothers and fluoride
treatments to vulnerable children.

Project Objectives

The measurable objectives of this project were to: 1) Apply dental
fluoride varnish to 40% of the children at each site between the eruption
of first tooth buds to five years old in order to reduce the number of
cavities in these children by 25%; 2) Enhance the oral health education
of 40% of pregnant women and mothers at each site by demonstrating
age appropriate oral health techniques; 3) Assist primary caregivers
to establish a dental home for 75% of the children by age one as
recommended by the American Association of Pediatrics and the
American Association of Pediatric Dentistry or after 2 years in the
program; 4) Expand the scope of practice for RDs in standardized oral
health assessment and fluoride varnish application; 5) Use NPs, RDs,
and RNs to apply fluoride varnish apart from well and sick baby visits;
and 6) Provide cross-training opportunities for NPs, RDs, and RNs in
oral health.

Materials and Methods

WIC program sites are ideal to implement this intervention. The
WIC mission is to safeguard the health of low income women, infants,
and children and the relationship between oral health, a healthy diet and
good nutrition support this important initiative. WIC offers access to
the at-risk population and regular contact because new and continuing
WIC clients who must come in every 3 months to receive their food
coupons. Every 6 months a recertification (verification of eligibility) is
completed along with health and nutrition histories.

At most WIC locations nationwide, RDs assess nutritional status,
provide nutrition counseling and prescribe food packages. RNs
provide similar services at some locations. Each client meets for an
individualized nutrition session in which an assessment is completed
and nutrition risk determined for each client. Nutrition counseling is
provided on areas of risk and referrals for other assistance are made as
needed. WIC coupons for specific food packages are given for the next
3 months. There also is a visit every 3 months at which clients get more
coupons and participate in nutrition education programs.

Counseling the primary caregiver about the importance of
establishing a dental home for the child and other oral health education,
followed by an oral health assessment and application of the fluoride
varnish was completed during one of these 2 visits and again 6 months
later. The routine visit with WIC staff will continue unchanged.

WIC clients were invited to participate in the oral health intervention and parents provided consent for their child to receive
fluoride varnishing. Special care was taken in recruitment to avoid
any hint that participation in the project will impact receiving food
coupons. Mothers/primary child care provider received oral health
education and counseling about oral health hygiene. After informed
consent, the Project staff assessed the child’s oral health and applied
varnish as indicated. Project staff worked with the mother to find a
dental home for the child. Project staff conducted orientation sessions
for WIC staff explaining project activities.

4. The child is seen every 6 months until the study is complete in
three years or until the child is too old to participate (reaches
their 5th birthday).

5. The RD or NP gave the guardian or parent a list of dentists that
the child may be able to receive dental care.

6. After the fluoride varnishing procedure, the parent or guardian
was given a satisfaction survey.

7. After the first time visit the child was given a goodie bag
containing: Information pamphlets on good dental hygiene
Toothbrush, toothpastes, coloring book, crayons, etc. (Figure 2).

Figure 2: First child seen at one of the WIC sites leaving with her yellow goodie
bag.

Target geographic area

The immediate target area was two counties, an urban county and
a rural county, in Ohio. Thereafter, depending on the success of the
project, the target area is the entire state of Ohio, and if possible, those
WIC sites in the United States which do not have a fluoride program.
Expanding this intervention to other locations is voluntary on the part
of WIC. For this pilot demonstration project, two WIC locations have enthusiastically agreed to participate, with the approval of the ODH
Bureau of Nutrition Services. The urban site hosts 2,400 clients, 1,400
of whom are infants and children, while the rural site has 3,251 clients,
which includes 743 women, 894 infants, and 1,614 children.

Target beneficiary

Approximately 4,000 children were projected in the rural and urban
counties to be the beneficiaries of this project. Family gross income
must fall at or below 185% of the U.S. Poverty Income Guidelines.

Nurse Practitioners (NPs), Registered Dietitians (RDs), and
undergraduate/graduate nursing and nutrition students were also
involved in the project. At each WIC location there is an individual (RD
or NP) trained to apply fluoride varnish (FV) the teeth of WIC clients’
from the appearance of a child’s first tooth bud through four years of
age. By training NP’s, RD’s, and RN’s to perform oral health assessment,
fluoride varnishing, education, and other preventative care measures
could reduce poor oral health in high risk populations.

Results

Demographics

The project ended in Dec. 2013 and the first goal was met as 4091
children participated in program with 1813 children in the urban
county and 2278 children in the rural county. Over 1,700 of the children
participating in the project (or 41.6%) have returned for a second follow
up visit, and 658 (or 16.1%) have been seen for a third visit. Over 180
children (4.4%) have been in the program long enough to have received
a fourth fluoride varnish, and even 22 of them have had a fifth varnish
(0.5%) (Table 2). In the urban county, 61.5% of the children were black:
26.9% of the children were white: 3.8% of the children were Biracial,
and 7.7% were Asian. In the rural county, 27.9% of the children were
black; 66.3% of the children were white; 2.3% of the children were
biracial, and 3.5% of the children were Asian.

Program Participation

WIC Site

Both Sites
Combined

Urban

Rural

n

%

n

%

n

%

Visit 1

1,813

44.3

2,278

55.7

4,091

100

Visit 2

697

41.0

1,005

59.0

1,702

100

Visit 3

231

35.1

427

64.9

658

100

Visit 4

43

23.6

139

76.4

182

100

Visit 5

3

13.6

19

86.4

22

100

Table 2: Program Participation (number of children ever varnished).

Dental screening record results

This section outlines the results from the dental screening record.
The dental screening record is a form designed to capture several
criteria regarding the program participant’s dental characteristics.
Such characteristics include the status of the gums and the number of
missing, broken, decayed/discolored, filled, and silver capped teeth. The
dental screening record also captures the child’s age and gender, as well
as a host of materials and topics discussed with the child’s caregiver
(parents or guardians).

Figure 3 on the following page presents information about the
mean ages of the children varnished up to five times through the Oral
Health Project at each successive program visit. Results are depicted for
each site as well as for the overall project combined.

Figure 3: Child’s Mean Age at Each Oral Health Program Visit (in years).

Oral health habits as reported by parent/guardian

The Parent/Guardian Oral Health Survey is an instrument aimed at exploring children’s oral health habits as reported by their parents or
guardians is reported for Tables 3-5. Table 3 also reports on the child’s
dietary practices as reported by the parent. Tables 3 and 4 address visits
to the dentist and cleaning or brushing of teeth as reported by the
parent/guardian.

Table 3 indicates that urban caregivers are more likely to report that
their children snack on high sugar foods more than once a day or drink
more than one cup of a sweet drink per day. This was especially the case
for the first visit, but this difference waned in the case of snacks as visits
progressed but not in the case of sweet drinks.

Oral health habits

Tables 4 and 5 outlines the results of two important oral health
indicators: recent dentist visits and daily teeth brushings. In general,
caregivers of the urban study participants were more likely to indicate
their child had seen a dentist within the past six months compared
to rural study participants. For instance, 26.1% of urban caregivers
reported their child had seen a dentist within the past six months
(at their first program visit) compared to 18.8% of rural caregivers at
their first visit. The difference was even more dramatic at the second
visit when 40.9% of urban caregivers reported their child had seen a
dentist and only 23.6% of rural caregivers reported their child had seen
a dentist.

A notable dynamic seen in the dental visits data is that the proportion
of children seeing a dentist within the past six months increased with each subsequent visit. For instance, 22.1% of all participating children
were said to have seen a dentist in the past six months at the first visit.
By the second visit the proportion had increase to 30.8% and then to
38.1% by the third visit.

Although not significant, there was the same dynamic of increased
activity with each subsequent visit with children’s teeth brushing
activity. For instance, 90.3% of all participating children were said to
have cleaned or brushed their teeth daily at their first program visit.
At the second visit this percentage had increased to 95.9% and then to
96.3% at the third visit.

Early longitudinal comparisons

The following section outlines some early longitudinal analysis for
child participants in the Oral Health Project. The analysis examines (1)
daily teeth cleaning/brushing activity and (2) dental visits within the
past six months for children tracked longitudinally in the program with
at least two program visits, and up to three program visits (Table 4).

Teeth Cleaning/Brushing

Table 5 outlines a comparison of the same children with at least
three visits to the program in terms of cleaning and brushing of teeth at
least once daily between first and second visits, as well as a comparison
of the same children from the second to third visits on the same two
variables. Further this table presents the means (average proportions)
for each visit, and significance test results for the difference of means
results. (Pleases note: “Same” children are defined as those children
tracked longitudinally. Each child had at least a second program visit and possibly a third visit. Their caregiver’s form or survey responses
were linked and compared for analysis.)

The proportion of caregivers reporting that they cleaned or brushed
their children’s teeth at least once daily increased from an average of
90.1% for the first program visit to 95.7% for the second program
visit, when linking participant responses, across both sites. In the case
of the urban comparison site, the proportion of caregivers reporting
brushing or cleaning their child’s teeth daily increased from an average
of 87.1% for the first program visit to 96.6% for the second program
visit, when linking participant responses. At the rural comparison site,
the proportion of caregivers reporting brushing or cleaning their child’s
teeth daily increased from an average of 92.1% for the first program
visit to 95.1% for the second program visit. In both instances, these
increases were statistically significant.

In examining changes on the brushing or cleaning the child’s gum
or teeth variable between the second and third visits, no significant
change was found. This was likely attributable due to a ceiling effect,
where many parents were already reporting brushing or cleaning their
child’s teeth or gums. For instance, 98.0% of urban parents were already
reporting cleaning and brushing their children’s teeth at the second and
third program visits. Likewise, rural caregivers also reported high rates
of teeth cleaning and brushing (Table 5).

Dental visits

Table 6 outlines a comparison of the same individual children with
at least three visits to the program in terms of seeing a dentist between first and second visits, as well as a comparison of the same children
from the second to third visits on the same two variables Further this
table presents the means (average proportions) for each visit, and
significance test results for the difference of means results.

In Table 6, the proportion of the same children seeing a dentist in
the past six months has significantly increased for the children involved
in the program between the first and second visits. As a case in point,
the proportion of caregivers reporting that they have taken their child
to the dentist in the past six months increased from an average of 17.7%
for the first program visit to 31.4% for the second program visit, when
linking participant responses. Moreover, the proportion of caregivers
reporting taking their child to the dentist increased from an average of
23.1% from the second program visit to 38.0% for the third program
visit. In both instances, these gains were statistically significant
increases.

For the urban comparison site, the proportion of caregivers
reporting that they have taken their child to a dentist within the past
six months increased from an average of 24.0% for the first program
visit to 41.5% for the second program visit, when linking participant
responses. Furthermore, when comparing those participating in
both a second and third program visit, the proportion of urban
caregivers reporting that they have taken their child to a dentist
within the past six months increased from an average of 33.8% for the
second program visit to 45.7% for the third program visit. Likewise,
the proportion of rural caregivers reporting that they have taken
their child to a dentist within the past six months increased from an average of 17.2% for the second program visit to 33.7% for the
third program visit. In all four cases, these increases were statistically
significant changes (Table 6).

Urban

Rural

Combined

(n=638)

(n=880)

(n=1518)

1st Visit

2nd Visit

1st Visit

2nd Visit

1st Visit

2nd Visit

First to Second Visit

24

41.5**

13.1

24.0**

17.7

31.4**

Urban
(n=219)

Rural
(n=395)

Combined
(n=614)

2nd Visit

3rd Visit

2ndVisit

3rd Visit

2ndVisit

3rd Visit

Second to Third Visit

33.8

45.7**

17.2

33.7**

23.1

38.0**

** Significant at <0.001 level

Table 6: Comparison of Same Children Seeing Dentist in Past Six Months (average
percent).

Reasons for not going to the dentist

Also collected on the Parent Guardian Oral Health Survey form is
the parent/guardian’s self-reported reasons for not seeing a dentist with
their child within the past six months. Table 7 presents the results for
parents’ reasons at each of the first three program visits for not seeing
a dentist. The analyses took all children at first visit whose parents/guardians reported not seeing a dentist within the past six months.
These children were then tracked on the second and third visit.

Reason Given:

Program Visit

Visit 1

Visit 2

Visit 3

Urban (n=566)

Rural (n=932)

Total (n=1498))

Urban (n=134))

Rural (n=378))

Total (n=512)

Urban (n=24)

Rural (n=129)

Total (n=153)

My child is too young

64.1

86.1

77.8

61.9

76.5

72.7

70.8

72.1

71.9

I don’t know a dentist

11.5

7.9

9.3

9

8.7

8.8

4.2

9.3

8.5

fear going to the dentist

1.8

2.5

2.2

2.2

3.4

3.1

0

0.8

0.7

We do not have dental insurance

4.8

0.2

1.9

3

0.8

1.4

8.3

0.8

2

Transportation is a problem

3.2

0.6

1.6

5.2

0.5

1.8

0

0.8

0.7

We cannot afford to go

1.8

0.2

0.8

0

0

0

4.2

0

0.7

Don’t accept Insurance

1.4

0.2

0.7

3

0

0.8

0

0

0

Table 7: Parent/Guardian Reasons for Child not Seeing a Dentist at Each Visit (in percent).

As the Table 7 reveals, by far the primary reason for not seeing a
dentist is the misbelief that the child is still too young to see a dentist
– despite the best efforts of the clinical staff to ensure parents that their
child needs to be seen by a dentist. Over three-quarters, or 77.8%, of
the caregivers that had not taken their child to a dentist (at the first
program visit) indicated they had not done so because they thought
their child was too young. It has been suggested that this pattern is due
to some parents encountering dentists who will not see their children
because he or she is too young.

The next leading reason cited by caregivers for not taking their
child to a dentist (at their first program visit) was not knowing a
dentist, or perhaps a dentist that treats young children to go to, with
9.3% non-dentist-seeking caregivers indicating this was the case. Only
2.2% of non-dentist-seeking caregivers reported (at their first program
visit) that they had not taken their child to the dentist because they or
their child feared the dentist. Smaller portions of non-dentist-seeking
caregivers reported

(at their first program visit) that they had not taken their child to
the dentist because of issues with transportation, affordability or the
ability to pay, or issues with dental insurance or Medicaid (Table 7).

Topics discussed at program visits

Table 8 presents the topics discussed by the staff with the parent at each WIC oral health visit. The fact that at the WIC site “encouraging
dental visits” continues at a pretty high rate even at the third visit
suggests that perhaps the clinician there is having less success in having
the rural families follow her advice or there are less providers.

Discussion

The goals of the project.

Goal 1: Improve oral health disease in this WIC population.

Goal Met

On the basis of WIC figures, we projected a total target children’s
population of about 4000 children at an urban and rural WIC site for
preventive fluoride varnishing and education. In fact, even with several
months remaining in the project, we have been able, with parental/
guardian permission, to examine and varnish the teeth of about
4100 children at least once (Table 2). A few more than 1700 had two
varnishes, and about 700 will have had three varnishes at the conclusion
of this project. The data also indicate that we have been able to reduce
oral health disease.

Goal 2: Increase interprofessional collaboration by using NPs, RDs,
and RNs to conduct oral health assessments and apply dental fluoride
varnishes to at-risk children under five years of age; and

Goal 5: Increase interprofessional collaboration by using NPs,
RDs, and RNs to conduct oral health assessments and apply dental
fluoride varnishes to at-risk children through 4 years of age with
dentist (Table 8).

Goals 2, 4, and 5 Met

During the course of this grant, NP’s who are nurses with advanced
degrees, taught registered dietitians (RD) how to place children in a
comfort position of a child/caregiver’s choice, assess a child’s oral health
through the conduct an oral examination, apply fluoride varnish to
the child’s teeth, chart appropriately, and educate children and adults
as needed. The two disciplines also taught their students the same
activities and authenticated and authorized their activities with a
certificate when the student’s completion of activities met completion
and practice standards.

The two disciplines were able to conduct these activities and meet
the standards with little difficulties. Students were able to learn the
oral assessment, fluoride varnishing and welcomed having a certificate
showing their achievement. Faculty and students saw fluoride
varnishing and assessments as an opportunity to expand their scope of
practice and demonstrate their competence.

6) Overcome oral health barriers by using best practices and
educational materials from established effective nutritional and oral
health professionals and programs

Goals 3 and 6 Met

The services we have provided at both WIC sites were extremely
well liked by the dietetic and staff personnel, as well as the patients, at each site. We were requested to stay, if possible. The project has
continued to strive to get more parents connected with a “dental home”
(i.e., a steady patient-dentist relationship) at first visit. However the
informal feedback received suggests that many caregivers are being
turned down by dentists due to their children being too young. There
may be an opportunity here to begin a dialog within the community as
to the appropriate time for caregivers to begin taking their children to
the dentist.

Another area for possible improvement for oral health is related
to children’s dietary practices, as reported by the parents/guardians at
visits. Nevertheless, the project should be commended for the progress
in educating and socializing caregivers in terms of dental care.

Conclusions

The model could be adapted to other programs, such as Head Start
programs or at immunization clinics. The project can be sustained by
changing Federal and state reimbursements guidelines because current
guidelines limit such reimbursements to FV. Such reimbursements can
permit expansion of services at WIC locations leading to the possibility
of increasing the future dental capacity at WIC participants.

The project had four strengths. 1) A large group of at-risk children,
who had limited access to dental healthcare, were systematically
identified and preventively treated with fluoride varnish. 2) The dental
workforce was expanded to include other professionals, i.e., NPs, RDs,
and RNs, thus helping relieve the current strain on dentists and underserviced
dental areas. 3) Alternative financial reimbursement options
and increasing professional scope of practice provided models for
controlling health care costs. 4) Cross-disciplinary healthcare solutions
provided a model for interprofessional work and offered opportunities
for further collaboration in dental and other health needs, particularly
relating to prevention and treatment.

Acknowledgments

Funded by the Kellogg Foundation. Katherine Zheng BSN research assistant
for her help on the manuscript. Improving Oral Health of Young Children: An
Interprofessional Demonstration Project.